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7.6 MANAGEMENT OF BLEEDING/HAEMOSTASIS 7.6.1 Hemostatic Abnormalities in Dengue Infection The hemostatic changes that occur in dengue infection are considered to be the result of endothelial activation.92, 93 This process may aggravate thrombocytopenia in addition to the activation of coagulation pathways which are an inherent part of the disease.92, 93, 94 However, thrombocytopenia and coagulation abnormalities would not reliably predict bleeding in dengue infection. 47, 48 Markers of endothelial activation such as elevated levels of thrombomodulin, tissue factor and Von Willebrand factor are more often seen in severe dengue fever.95, 96 Increased levels of these proteins may indicate microvascular thrombosis and endorgan damage.97
7.6.2 How to Recognize Significant Occult Bleeding? Bleeding is considered significant when it results in hemodynamic instability. Bleeding from the gums or per vagina, epistaxis and petechiae are common but will usually cease spontaneously and are often not significant.3 Significant bleeding can a consequence of disseminated intravascular coagulation which usually occurs following prolonged shock and acidosis.46
Suspect significant occult bleeding in the following situations: 1. Hematocrit not as high as expected, for the degree of shock to be explained by plasma leakage alone. 46 2. A drop in hematocrit, without clinical improvement, despite adequate fluid replacement 46, 81 3. Severe metabolic acidosis and end-organ dysfunction despite adequate fluid replacement.46